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Wednesday, March 19, 2014

Safety II – Re-defining Safety (and the way you look at it)

One of the big problems with the safety profession is how
difficult it is to define what we’re trying to achieve. Numerous definitions of
safety exist (we’ve even talked about a few here and here), but these
definitions often seem to describe more about the worldview of the authors
(e.g. those that describe safety as the absence of accidents versus those that
describe it as an acceptable risk level, or some variation thereof) than give
us guidance on what we, as a profession, are trying to achieve, much less how
we achieve any goal.

Even still, one common theme exists amongst all such
definitions – they are focused on a negative. Safety is almost always defined
by the absence of something – absence of accidents, absence of risk, absence of
hazards, absence of harm, etc. By defining safety in this way the implication
is that our job is to remove, to constrain. Typically getting into the system,
finding what’s broken, and either fixing it or replacing it is our way of
achieving this. This process applies whether the broken component is a piece of
equipment or a person (i.e. human error). The further implication here is that
behavior of both people and parts is bi-modal – either it works or it doesn’t.
And the things that cause the component (either the person or the part) to work
are different than the things that cause the component to not work. Therefore,
our job as safety professionals is to prevent the causes of the bad behavior
and to constrain the good behavior to keep it from turning into bad behavior
through procedures, training, work-rules, etc. This basic approach to safety
management has been termed “Safety I” by safety researcher Professor Erik Hollnagel and others.

However, although this line of bimodal thinking applies to
parts, it doesn’t work well with people. Consider the following points:

The underlying “causes” of either “safe” or “unsafe” human
behavior are the same – human capacity for adaptation and innovation.

Adaptability and innovation are not inherently bad. They are
at least partly (if not entirely) responsible for all of the advances in human
civilization. But in some contexts they contribute to accidents.

Workers don’t usually come to work to get hurt or killed
(although they sometimes do). So, deep down, everyone cares about safety.

Workers combine their innate capacity to innovate and adapt
to balance often competing goals (production, safety, quality, etc.) in ways
that are hard to predict, but are easy to see (assuming you are looking for it).

If this is all true, what if instead of trying to constrain
behavior and get rid of all the “unsafe” behaviors and “human errors” we
instead accepted that human performance will always have a variability to it
and that this isn’t always bad. In fact, if you think about it, most of the
time nothing goes wrong. Why is that? If we’re honest with ourselves we’ll
admit that it’s because of the ability of the workers to create safety in spite
of the imperfect systems that they operate in.

So if we use the Safety I line of thinking, trying to
constrain behavior through the use of procedures, training, and bureaucracy, we
may actually constrain the very thing that’s creating safety in our
organizations.

What if, instead of using only the Safety I line of
thinking, we complemented Safety I with a new paradigm that Hollnagel has
termed Safety II? Safety II suggests that instead of defining safety as the
absence of a negative, instead we should define safety by our ability to
achieve success under varying conditions, or, safety should be defined not by
the number of accidents, but by the number of successes. Think of it this way,
if the roots of success and failure are similar, then only looking at the rare
times that accidents happen only tells us a small part of the story.

Safety II is still a relatively new concept, so new that
models and mechanisms for implementing Safety II concepts are rare. However,
some immediate suggestions from Safety II are apparent:

Since workers are one of the primary sources of safety in
the organization, make sure you open channels to learn and share experiences.
Get out from behind your desk and go observe how work is getting done. Be
careful to avoid the Safety I mindset while doing this, of looking for unsafe
behaviors. Just observe the innovation and creativity and ask how you can
enhance it to increase the likelihood of success.

Dedicate some of the investigation resources to
investigation how and why things succeed. Sure we need to keep investigating
incidents, but because success and failure spring from the same sources,
there’s learning to be had from successful jobs. Get out there and find it!

While conducting incident investigations, don’t just focus
on what went wrong. Instead, identify how things normally work and why that
normally succeeds. Then determine why this time was different.

Safety II presents numerous other opportunities for the
safety profession (including the potential to eliminate the conflict between
safety and production). Let us know your thoughts on the opportunities and
challenges of this new paradigm in safety.